Citation Nr: 0002319 Decision Date: 01/28/00 Archive Date: 02/02/00 DOCKET NO. 99-06 179A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to an initial evaluation in excess of 20 percent for peripheral neuropathy, right upper extremity. 2. Entitlement to an initial evaluation in excess of 10 percent for peripheral neuropathy, right lower extremity. 3. Entitlement to service connection for diabetes mellitus. 4. Entitlement to service connection for cerebral vascular accident (CVA) with neurological impairment, left upper and lower extremities. 5. Entitlement to service connection for arthritis, multiple joints. 6. Entitlement to service connection for traumatic arthritis, multiple joints. 7. Entitlement to service connection for beriberi. 8. Entitlement to service connection for malnutrition. 9. Entitlement to service connection for ischemic heart disease. ATTORNEY FOR THE BOARD Tresa M. Schlecht, Counsel INTRODUCTION The veteran had active service from May 1943 to December 1945. From November 1944 to May 1945, he was a prisoner of war (POW) of the German government. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 1998 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio, which granted service connection for peripheral neuropathy, right upper extremity, and assigned a 20 percent evaluation for that disability. The RO also granted service connection for peripheral neuropathy, right lower extremity, and assigned a 10 percent evaluation for that disability. The RO denied entitlement to service connection for diabetes mellitus, CVA with neurologic impairment, arthritis of multiple joints, traumatic arthritis of multiple joints, beriberi, malnutrition, and ischemic heart disease. In his substantive appeal, the veteran requested a hearing before the Board. However, in May 1999, he withdrew that request. The examiner who conducted a March 1998 VA examination concluded that the veteran had bilateral peripheral neuropathy of the lower extremities. The RO has granted service connection for peripheral neuropathy of the right lower extremity, but has neither granted nor denied entitlement to service connection for peripheral neuropathy of the left lower extremity. The Board is required to review all issues which are reasonably raised from a liberal interpretation of the appellant's substantive appeal. Meyers v. Derwinski, 1 Vet. App. 127 (1991); EF v. Derwinski, 1 Vet. App. 324 (1991); see 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 20.202 (1999). The Board is of the opinion that a claim for entitlement to service connection for peripheral neuropathy of the left lower extremity is reasonably raised. This issue is therefore referred to the agency of original jurisdiction. The Board notes that remand is not proper at this time, as the RO has not made an initial determination regarding the referred issue. See Manlinicon v. West, 12 Vet. App. 238 (1999). FINDINGS OF FACT 1. Disability of the right upper extremity is manifested by marked atrophy of the intrinsic muscles of the right hand. 2. The veteran's service-connected peripheral neuropathy, right lower extremity, is currently manifested by a decreased deep tendon reflex at the right knee, absent right ankle jerk, decreased sensation to pin-prick in a stocking/glove pattern, and absent vibratory sense in the right ankle. 3. There is no medical evidence linking the veteran's current diagnosis of diabetes mellitus to his active service or to his history as a former prisoner-of-war (POW). 4. There is no medical evidence linking the veteran's current diagnosis of CVA with neurologic impairment to his active service or to his history as a former POW. 5. There is no medical evidence linking the veteran's current diagnosis of arthritis, multiple joints, to his active service or his history as a former POW. 6. There is no medical evidence of a diagnosis of traumatic arthritis of any joint. 7. The veteran experienced malnutrition and had beriberi while a POW, but there is no medical evidence of a current diagnosis of either condition, and there are no current medically-diagnosed residuals of malnutrition or beriberi except peripheral neuropathy, for which service connection has already been granted. 8. There is no evidence that the veteran had localized edema while a POW or as a result of his internment, and there is no evidence of a medical diagnosis of beriberi heart disease or medical evidence linking a current diagnosis of ischemic heart disease to the veteran's service or to his history as a POW. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation in excess of 20 percent for peripheral neuropathy, right upper extremity, are not met. 38 U.S.C.A. §§ 1155, 5107(b) (West 1991); 38 C.F.R. § 4.124a, Diagnostic Code 8512 (1999). 2. The criteria for an initial evaluation in excess of 10 percent for peripheral neuropathy, right lower extremity, are not met. 38 U.S.C.A. §§ 1155, 5107(b) (West 1991); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (1999). 3. The veteran has not submitted a well-grounded claim of entitlement to service connection for diabetes mellitus. 38 U.S.C.A. § 5107(a) (West 1991). 4. The veteran's claim of entitlement to service connection for cerebral vascular accident with neurologic impairment, left upper and lower extremities, is not well-grounded. 38 U.S.C.A. § 5107(a) (West 1991). 5. The veteran's claim of entitlement to service connection for arthritis, multiple joints, is not well-grounded. 38 U.S.C.A. § 5107(a) (West 1991). 6. The veteran's claim of entitlement to service connection for traumatic arthritis, multiple joints, is not well- grounded. 38 U.S.C.A. § 5107(a) (West 1991). 7. The veteran's claim of entitlement to service connection for beriberi is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 8. The veteran's claim of entitlement to service connection for malnutrition is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 9. The veteran's claim of entitlement to service connection for ischemic heart disease is not well-grounded. 38 U.S.C.A. § 5107(a) (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The veteran claims that he has various disabilities related to his experience as a POW. In particular, the veteran asserts that arthritis or traumatic arthritis developed in multiple joints as a result of sleeping on the ground while he was a POW. He also asserts that he suffered from beriberi and malnutrition caused by lack of adequate diet. He also contends that he has ischemic heart disease and sustained a CVA with neurologic impairment, left extremities, and is a diabetic, as a result of the stress induced by his internment as a POW. The veteran also contends that he is entitled to higher initial evaluations for service-connected peripheral neuropathy, right upper extremity and right lower extremity. A person who submits a claim for benefits under a law administered by the Secretary shall have the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. 38 U.S.C.A. § 5107(a) (West 1991); Carbino v. Gober, 10 Vet. App. 507 (1997), Anderson v. Brown, 9 Vet. App. 542, 545 (1996). A well-grounded claim is "a plausible claim, one which is meritorious on its own or capable of substantiation. Such a claim need not be conclusive but only possible to satisfy the initial burden of [Section 5107(a)]." Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). Until a well-grounded claim is established, the duty to assist does not attach. See Epps v. Gober, 126 F.3d 1464, 1468-70 (Fed. Cir. 1997). The veteran's contentions as to the propriety of the initial evaluations of his service-connected peripheral neuropathy present well-grounded claims. See Fenderson v. West, 12 Vet. App. 119 (1999). Disability evaluations are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.1 (1999). Where an appeal arises from an initial rating decision which established service connection and assigned the initial disability evaluation, the entire period of initial evaluation is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. Fenderson v. West, 12 Vet. App. 119 (1999). As to each of the veteran's claims for service connection, in order to establish a well-grounded claim, there generally must be (1) a medical diagnosis of a current disability; (2) medical or, in certain circumstances, lay evidence of in- service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between an in-service injury or disease and the current disability. See Anderson, supra; Caluza v. Brown, 7 Vet. App. 498, 506 (1995), Service connection can also be established on a presumptive basis for certain chronic disabilities when the evidence shows that a veteran served for 90 days or more during a period of war, and the disability becomes manifest to a degree of 10 percent or more after active military service, notwithstanding that there is no evidence of the disability during the period of service. 38 U.S.C.A. § 1112; Fenderson v. West, 12 Vet. App. 119, 125 (1999). If a veteran was a POW and was held captive for a period of not less than 30 days, post-traumatic osteoarthritis, beriberi (including beriberi heart disease), malnutrition (including optic atrophy associated with malnutrition), and peripheral neuropathy, except where directly related to infectious causes, shall be service connected if manifest to a degree of 10 percent or more at any time after discharge from service, notwithstanding lack of in-service evidence. 38 C.F.R. § 3.309(c); see Greyzck v. West, 12 Vet. App. 288, 291 (1999). These presumptions are rebuttable by affirmative evidence offered to the contrary. 38 C.F.R. § 3.307; Darby v. Brown, 10 Vet. App. 243, 246 (1997). A claim of service connection for a presumptive disease by a former POW is well grounded if the claimant presents a current diagnosis that the disease is 10 percent disabling. See Goss v. Brown, 9 Vet. App. 109, 113 (1996). The credibility of the evidence is presumed when determining whether a claim is well grounded. See King v. Brown, 5 Vet. App. 19, 21 (1993). 38 C.F.R. § 3.307(d) provides that evidence which may be considered in rebuttal of service incurrence of a disease listed in § 3.309 will be any evidence of a nature usually accepted as competent to indicate the time of existence or inception of disease, and medical judgment will be exercised in making determinations relative to the effect of intercurrent injury or disease. The expression "affirmative evidence to the contrary" will not be taken to require a conclusive showing, but such showing as would, in sound medical reasoning and in the consideration of all evidence of record, support a conclusion that the disease was not incurred in service. Summary of the Medical Evidence The veteran's service medical records are essentially devoid of any medical evidence pertinent to the claims at issue in this appeal. The service medical records reflect that the veteran weighed 185 pounds on examination for active duty, and weighed 177 pounds at the time of separation examination in December 1945. The records tend to establish that the veteran was a POW. The veteran's initial post-service application for benefits, submitted in February 1946, is essentially devoid of evidence pertinent to the claims on appeal. The veteran's November 1982 VA examination is also essentially devoid of evidence pertinent to the claims on appeal. The summary of private hospitalization in March 1995 reflects that the veteran sustained an acute CVA. An old inferior wall myocardial infarction (MI) was also diagnosed. The summary of private hospitalization from June 1995 to July 1995 reflects that congestive heart failure was diagnosed after an acute onset of shortness of breath. It was also determined that use of insulin was required to control diabetes mellitus. On VA examination conducted in March 1998, the veteran reported losing his toenails as a result of beriberi while a prisoner of war. The veteran reported a history of diabetes mellitus since 1985. The veteran also reported residual left-sided weakness as the result of a CVA and MI in March 1995. There was atrophy of the intrinsic hand muscles. There was no tremor or fasciculation of the right hand or arm. Deep tendon reflexes were 2/4 on the right and 3/4 on the left through the knee. Ankle jerks were 0/4 bilaterally. There was decreased pinprick sensation in a stocking-glove fashion to the knees bilaterally. There was no vibratory sense in the right ankle. The diagnostic impressions and diagnoses included, in pertinent part: beriberi while in service secondary to malnutrition as a POW; residuals of stroke; diabetes mellitus; cerebrovascular disease; coronary artery disease, status post MI and congestive heart failure; and, peripheral neuropathy, "likely secondary to a combination of diabetes mellitus and remote malnutrition." Another VA examiner stated that the veteran had peripheral neuropathy in the lower extremities bilaterally "could be" a manifestation of beriberi suffered as a POW. 1. Claim for Increased Initial Evaluation, Peripheral Neuropathy, Right Arm The medical evidence reflects that the only current neurologic impairment of the right upper extremity is marked atrophy of the intrinsic hand muscles. While the general medical examiner noted the veteran had an intention tremor of the right hand, the neurologic examiner specified that there was no tremor. There is no other diagnosis of a tremor of the right hand in any other medical evidence or opinion of record. The preponderance of the medical evidence establishes that the veteran does not currently have an intention tremor of the right hand. No other abnormality or neurologic sign, symptom, or finding as to the right upper extremity was noted. The veteran's service-connected right upper extremity disability is evaluated under 38 C.F.R. § 4.124a, Diagnostic Code 8512, which provides the criteria for evaluations of complete or incomplete paralysis of the lower radicular nerve group of either upper extremity, with evaluation of neuritis (Diagnostic Code 8615) or neuralgia (Diagnostic Code 8715) rated as for incomplete paralysis under Diagnostic Code 8512. Mild incomplete paralysis warrants a 20 percent evaluation. Moderate incomplete paralysis of the lower radical nerve group of the major extremity warrants a 40 percent evaluation. Complete paralysis of the lower radical nerve group of the major extremity, warrants a 70 percent evaluation. The provisions of 38 C.F.R. § 4.120 dictate that neurologic disabilities are ordinarily rated in proportion to the impairment of motor, sensory or mental function, with special consideration of complete or partial loss of use of one or more extremities, disturbances of gait, tremors, visceral manifestations, injury to the skull, etc. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory disturbances. The provisions of 38 C.F.R. § 4.123 provide that neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. In this case, the only medical evidence of any abnormality or symptomatic manifestation of impairment of the right hand is atrophy of the intrinsic muscles. There is no evidence of complete paralysis of the right hand or of atrophy of any other muscle group. This objective finding, in the absence of any other evidence of abnormality of the right hand, warrants a finding of mild incomplete paralysis, so as to meet the criteria for a 20 percent evaluation, but no more. The preponderance of the evidence is against a finding that the veteran's peripheral neuropathy of the right upper extremity met the criteria for an evaluation in excess of 20 percent at any time during this initial evaluation period. 2. Claim for Increased Initial Evaluation, Peripheral Neuropathy, Right Leg The veteran's service-connected right lower extremity disability is evaluated under 38 C.F.R. § 4.124a, Diagnostic Code 8520, which provides the criteria for evaluation of paralysis of the sciatic nerve. Under Diagnostic Code 8520, a 10 percent rating is warranted for incomplete mild paralysis of the sciatic nerve; 20 percent is warranted for incomplete moderate paralysis; and, 40 percent is warranted for incomplete moderately severe paralysis. Neuritis (Diagnostic Code 8620) or neuralgia (Diagnostic Code 8720) may be evaluated as for incomplete paralysis under Diagnostic Code 8520. When the involvement is wholly sensory, the rating is for mild, or at most, the moderate degree. See 38 C.F.R. § 4.124a. In this case, the medical evidence reflects that the veteran has decreased deep tendon reflexes, decreased sensation to pinprick, and lacks vibratory sense at the knee, in the left lower extremity. However, there is no evidence of loss of motor strength or function of the right lower extremity. While the evidence reflects that the veteran has difficulty walking, and uses a wheelchair for more than short distances, the medical evidence reflects that it is impairment of the left lower extremity, not of the right lower extremity, which results in these functional limitations. The Board finds that the veteran's right lower extremity closely approximates sensory involvement only, so as to warrant a finding of mild incomplete paralysis, meeting the criteria for a 10 percent evaluation. The Board finds that decreased deep tendon reflexes, in the absence of any medical evidence of loss of motor function or functional ability, is not a disability of such severity as to approximate incomplete moderate paralysis. The Board finds that the evidence does not more nearly approximate the criteria for a 20 percent evaluation for peripheral neuropathy of the right lower extremity. See 38 C.F.R. § 4.7 (1999). The Board has also considered whether an increased rating on an extraschedular basis is warranted, for either right upper extremity or right lower extremity peripheral neuropathy. In exceptional cases where the schedular evaluation is found to be inadequate, pursuant to 38 C.F.R. § 3.321(b)(1), the Under Secretary for Benefits may approve an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 U.S.C. § 3.321(b)(1). This regulation "does not preclude the Board from considering whether referral to the appropriate first-line officials is required." Floyd v. Brown, 9 Vet. App. 88, 95 (1996); see also Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). In this case, the Board notes that the veteran has not presented any evidence that the residuals of peripheral neuropathy had required frequent hospitalizations, have required any outpatient medical treatment, or that they have markedly interfered with his employment or his activities of daily living. The Board agrees with the RO's apparent determination that referral for extraschedular consideration was not warranted. 3. Claims for Service Connection for Diabetes Mellitus and CVA While the record does contain evidence demonstrating that the veteran presently suffers from diabetes and from the residuals of a CVA, there is no medical evidence of in- service incurrence or aggravation of either disorder, nor is there any evidence of such disorders proximate to service, nor is there any evidence of a medical nexus between either disorder and his service. The veteran states that the etiology of his osteoarthritis was due to the hardships and trauma that he experienced as a POW. However, lay testimony is not considered competent medical evidence to establish the medical etiology of a disorder because lay persons are not competent to offer medical opinions. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Establishing service connection generally requires medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Caluza, 7 Vet. App. at 506; see also Grottveit, supra. While the veteran may testify as to events that occurred and as to symptoms, his lay opinion regarding etiology, even as to medical results of his experiences as a POW, is not sufficient to establish a well-grounded claim. The Board further notes that the onset of diabetes was diagnosed in the mid-1980's, and a CVA was diagnosed in the mid-1990's. Since neither of these diseases developed until nearly 40 years or more elapsed after the veteran's service discharge, it would be unreasonable for the Board to conclude that the diseases were linked to the veteran's service, or to his experiences as a POW, in the absence of medical evidence establishing such a link. As noted, there is no medical evidence to support the veteran's allegation that these diseases are related to the veteran's POW experiences. Diabetes is not among the diseases which may be presumed service-connected based on the veteran's status as a POW, nor is CVA among the diseases which may be presumed service- connected for a POW. See 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309. Thus, as to the claims for service connection for diabetes and CVA, the veteran has failed to satisfy the second and third Caluza requirements, and has not established well-grounded claims. The veteran has been notified, in the May 1998 rating decision and in the March 1999 statement of the case, regarding the evidence required to establish well-grounded claims generally, and of the specific evidence required to establish a well-grounded claim for service connection for arthritis or traumatic arthritis. He has not identified any additional medical evidence which might service to well ground the claims. Absent a well-grounded claim, the Secretary has no duty to assist the veteran to further develop the facts pertinent to the claim. Epps, 126 F.3d at 1469. The claims must be denied. 4. Claims for Service Connection for Arthritis and Traumatic Arthritis The veteran has failed to provide any medical evidence of in- service incurrence or aggravation of arthritis or any evidence of a medical nexus between arthritis and his service. Thus, as to the claim for service connection for arthritis of multiple joints, the veteran has failed to satisfy the second and third Caluza requirements. The record is negative for a diagnosis of post-traumatic osteoarthritis or a competent medical opinion linking current arthritis of multiple joints to the veteran's service. Without current evidence of a specific medical diagnosis of post-traumatic osteoarthritis, presumptive service connection for a POW who develops traumatic arthritis is not available. See 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309. In his attempt to establish a well-grounded claim, the veteran suggests that the etiology of his osteoarthritis was due to the hardships and trauma that he experienced as a POW. However, lay testimony is not considered competent medical evidence to establish the medical etiology of a disorder because lay persons are not competent to offer medical opinions. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). While the veteran may testify as to events that occurred and as to symptoms, his lay opinion regarding etiology, even as to medical results of his experiences as a POW, is not sufficient to establish a well-grounded claim. The veteran has been notified, in the May 1998 rating decision and in the March 1999 statement of the case, regarding the evidence required to establish well-grounded claims generally, and of the specific evidence required to establish a well-grounded claim for service connection for arthritis or traumatic arthritis. He has not identified any additional medical evidence which might service to well ground the claims. Absent a well-grounded claim, the Secretary has no duty to assist the veteran to further develop the facts pertinent to the claim. Epps, 126 F.3d at 1469. The claims must be denied. 5. Claims for Service Connection for Beriberi and Malnutrition In this case, although there is no evidence as to incurrence of beriberi or malnutrition in the veteran's service medical records, medical opinions stated in the March 1998 reports of VA examinations reflect that the veteran had beriberi secondary to malnutrition as a POW. The examination reports further reflect that the veteran has peripheral neuropathy, "likely secondary to a combination of diabetes mellitus and remote malnutrition." Another opinion reflects that the veteran's current diagnosis of peripheral neuropathy "could be a manifestation of beriberi suffered as a prisoner of war." The Board notes that beriberi and malnutrition are among the diseases which may be presumed service-connected if manifested to a degree of 10 percent or more any time after service. However, while the medical evidence reflects that the veteran likely incurred both malnutrition and beriberi while a POW, the only residual of either is peripheral neuropathy. The veteran has already been awarded service connection for peripheral neuropathy as a separate disease entity. Service connection may not be granted for beriberi, as there is no current diagnosis of beriberi. Similarly, there is no current diagnosis of malnutrition. Rather the assigned diagnosis is "remote malnutrition." While it would not be incorrect to characterize the veteran's award of service connection for peripheral neuropathy as "peripheral neuropathy, residual to beriberi and/or malnutrition," the fact that the RO did not so specify does not entitle the veteran to a separate award of service connection for beriberi or malnutrition unless or until there is medical diagnosis of beriberi or malnutrition as a current disease entity, or until there is medical identification of some current manifestation of those diseases for which the veteran has not yet been awarded service connection. The Board notes that, even if service connection were to be granted for the history of beriberi or malnutrition, such an award of service connection would not result in any benefit to the veteran. In the absence of evidence of any current disability other than peripheral neuropathy, there would be no manifestations ratable under the criteria for evaluation of service connection disabilities, since peripheral neuropathy, having already been separately evaluated, cannot be the basis of a compensable evaluation for either beriberi or malnutrition. 38 C.F.R. § 4.14 (evaluation of the "same disability" or the "same manifestation" under various diagnoses is to be avoided); see Brady v. Brown, 4 Vet. App. 203 (1993) (veteran may not receive separate ratings for a psychiatric disorder and physical symptoms associated with the disorder, because rating the conditions separately would compensate the veteran twice for the same disorder). 6. Claim for Service Connection for Ischemic Heart Disease There is no evidence of ischemic heart disease (ISD) or of localized edema in the veteran's service medical records. The veteran did not seek service connection for ISD in his 1946 original application for benefits. There is no post- service medical evidence of ISD in the veteran's November 1982 VA examination or subsequent private medical records prior to the 1990s, more than 40 years after the veteran's service separation. In a March 1998 history of his medical complaints related specifically to his status as a former POW (VA Form 10-0048), the veteran specifically denied that he experienced any swelling in the joints, legs or feet, or muscles, while in captivity. There is no medical evidence or opinion linking the veteran's current diagnosis of ISD to his active service or any incident thereof. The Board notes that presumptive service connection is applicable to establish a well-grounded claim where a former POW is diagnosed with beriberi heart disease. The regulations define beriberi heart disease as ISD in a former POW who experienced localized edema during captivity. 38 C.F.R. § 3.309(c), Note. There is no subjective allegation or objective medical evidence that the veteran had localized swelling or currently has a diagnosis of beriberi heard disease or ISD as a result of beriberi. The Board notes in particular that examiners who conducted VA examinations specifically noted the possibility of an etiologic link between beriberi and other medical conditions with which the veteran has been diagnosed, but did not indicate any link between the diagnosis of beriberi in service and current ISD. While there is no duty to develop a claim which is not well-grounded generally, the Board finds that any additional duty applicable in this case based on the veteran's status as a former POW has been met. 38 U.S.C.A. § 5107(a); Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). In the absence of any evidence that the veteran's ISD is related to beriberi, the presumption is not available to establish a well-grounded claim in this case. The Board has considered whether there is any medical evidence or opinion establishing service connection for ISD not diagnosed as related to beriberi. However, the record is devoid of any evidence to suggest service incurrence or aggravation of a cardiac condition. In the absence of any competent medical evidence or opinion relating ISD, which was first diagnosed more than 40 years after the veteran's separation from service, as required to establish a well- grounded claim generally, the veteran has not established a well-grounded claim. As noted above, the veteran has been advised of the evidence required to establish a well-grounded claim. The claim must be denied. ORDER An initial evaluation in excess of 20 percent for peripheral neuropathy, right upper extremity, is denied. An initial evaluation in excess of 10 percent for peripheral neuropathy, right lower extremity, is denied. Entitlement to service connection for diabetes mellitus is denied. Entitlement to service connection for cerebral vascular accident (CVA) with neurological impairment, left upper and lower extremities, is denied. Entitlement to service connection for arthritis of multiple joints is denied. Entitlement to service connection for traumatic arthritis of multiple joints is denied. Entitlement to service connection for beriberi is denied. Entitlement to service connection for malnutrition is denied. Entitlement to service connection for ischemic heart disease is denied. JOHN R. PAGANO Acting Member, Board of Veterans' Appeals